=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396707709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH C BENJAMIN ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 GRAMPIAN BLVD
-----------------------------------------------------
City | WILLIAMSPORT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17701-1909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-447-3569
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 303 MAIN ST APT 3
-----------------------------------------------------
City | BLOSSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16912-1161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-447-3576
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | RT003818
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------